Post on 28-Sep-2020
Patient Safety Executive Development ProgramInstitute for Healthcare Improvement
Welcome to Day 3!Please pick up your tent card and sit at your selected table.
“Insanity: doing the same thing over
and over again and expecting different
results.”
Albert Einstein, (attributed)
Human FactorsDoug Bonacum
This presenter has nothing to disclose.
Patient Safety Executive Development ProgramInstitute for Healthcare Improvement
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Session Objectives
• List three factors that degrade human performance
• Describe three error reduction strategies that take into consideration human factors principles
• Explain how to assess the work environment for human factors violations
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Human Error
1. Errors are common
2. The causes of errors are known
3. Many errors are caused by activities that rely on weak aspects of cognition
4. Systems failures are the “root causes” of most errors
Lucian Leape, “Error in Medicine” JAMA, 1994
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Human Error Reduction Strategies
“When it comes to shaping on-the-job
performance, there are 2 things that leaders
can influence: The design of work processes
staff use and the behavioral choices they
make to accomplish their work. Both affect
patient safety (and workplace safety and
service and affordability and…).
- adopted from David Marx
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Human Factors
• Human Factors focuses on human beings and their interaction with each other, products, equipment, procedures, and the environment
• Human Factors leverages what we know about human behavior, abilities, limitations, and other characteristics to ensure safer, more reliable outcomes
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Our Focus
• Understanding the ‘violations’ of human factors principles that set us up for errors
• Determining what to do to address these violations
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Nominal Human Error Performance
Redesign with HF in mind
HF Violations
Patient Safety Executive Development ProgramInstitute for Healthcare Improvement
Error-Producing Conditions
• Unfamiliarity with task x17• Shortage of time x11• Poor communication x10• Information overload x6• Misperception of risk (drift) x4• Inadequate procedures / workflow x3
These are compounded by “human factors violations” such as fatigue, stress, work environment (e.g., psychologically unsafe environment), interruptions and distractions, and ambiguity regarding roles and responsibilities.
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Human Factors Violations:Drivers of Human Error
• Fatigue• Lack of sleep• Shift work• Boredom,
frustration• Fear • Stress• Reliance on
memory• Reliance on
vigilance• Injury or Illness
• Interruptions & distractions
• Noise• Heat• Clutter• Motion• Lighting• Unnatural workflow• Procedures or
devices designed in an accident prone fashion
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Ve
ry U
nsa
fe S
pa
ce
Nevernever
‘illegalIllegal’space
UsualSpace ofaction
Expected safespace of action asdefined by professionalstandards
Neversometimes
Alwayssometimes
Alwaysalways
ACCIDENT
Market demand
Technology
IndividualConcerns
Performance
Safety regs & good practicesCertification/accreditation standard
How About Our Own Conscious Violations?
Violation Producing Conditions
• Perceived low likelihood of detection
• Inconvenience
• Misperception or lack of recognition of risk
• Authority / status to violate (self-perceived)
• Copying behavior
• No disapproving authority figure present
• Group pressure
{Primary Source Human Error Assessment & Reduction Technique, Jeremy Williams
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Human Factors Engineering (HFE)
• Physical demands
• Skill demands
• Mental workload
• Team dynamics
• Environmental conditions
Human Factors Engineering: Examines a particular activity in terms of its component tasks and then considers each task in terms of:
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Error Reduction Overview: Hierarchy of Controls
Standardization & Simplification
Policies,Training, Inspection
Minimize consequencesof errors
Make it easy to do the right thing
Make it hard to do the wrong thing
Eliminate the opportunity for error
HumanFactors
Mitigate
Facilitate
Eliminate
Make errors visible
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• Use visual controls
• Avoid reliance on memory
• Simplify and Standardize
• Use constraints/forcing functions
• Use protocols and checklists
• Improve access to information
• Automate carefully
• Reduce interruptions and distractions
• Take advantage of habits and patterns
• Promote effective team functioning
Specific Error Reduction Strategies
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Stove A
Stove B
Strategy: Use Visual Controls
Which dial turns on the burner?
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• Computerized drug-drug interaction checking
─Drug information databases
─Customized drug rules
• Preprinted orders
─Chemotherapy order form
─Pain management order forms
• Star$$$
Strategy: Avoid Reliance on Memory
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• Formulary restrictions
─Remove items
─Eliminate therapeutic duplications
─Limit availability
• Heparin weight based protocol
─Simplifies ordering process
─Provides comprehensive orders
• Reduce number of handoffs, number of steps in a process
Strategy: Simplify
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Why Simplify Workflow?
STEP 1 STEP 2 STEP 3 STEP 4
90% 90% 90% 90%
First step =
90%
Process reliability = 90% * 90% * 90% * 90% = 66%
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• Who, what, with what, when, where, how─Example from Reliability Session
─“Win / Win” - Less work, better care
• Standard solutions─Ease of ordering
─Ease of preparation
─Ease of administration
Strategy: Standardize
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• Concentrated KCl vials─Remove KCl from all inpatient units
• Connectors that prevent IV administration of enteral products
• Computer prompt: “Proceed Y or No?”
• And of course, In-N-Out Burger
Strategy: Use Constraints/Forcing Functions
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• Checklists
─Reminders of every step in the process
─NOT rigid molds for non-thinking behavior
─Pilot checklists: includes method to designate where stopped if interrupted
─Anesthesia Machine Checklist
Strategy: Use Protocols and Checklists
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WHO Surgical Safety Checklist
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• Include “Indication” with orders
• Drug information sources
─Determine ease of use
• Location of medication list/problem list
• Improving Medication Adherence
Strategy: Improve Access to Information
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• Errors multiply if input is incorrect
• Automated dispensing machines
• Computerized physician order entry
Strategy: Automate Carefully
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Strategy: Reduce Interruptions and Distractions
Patient Safety Executive Development ProgramInstitute for Healthcare Improvement
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Strategy: Take Advantage of Habits and Patterns
• Hand hygiene
• Appointment remindercard - questions
• Patient medication list
─Sleeve to hold insurance
card and
medication list
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Strategy: Promote Effective Team Functioning
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What Can You Do?
• Include human factors analysis in incident investigations
• Conduct a human factors task analysis:─Are processes standardized?
─ Is there ready access to information?
─Are redundancies and reminders in place?
─How many interruptions are there during the work shift?
─How complex are the tasks or instructions?
• Educate staff
“We can’t change the human condition, but we can change
the conditions under which humans work.”
James Reason32